The GE Portuguese Journal of Gastroenterology is the official publicatio of the Portuguese Society of Gastroenterology, Portuguese Society of Digestive Endoscopy and the Portuguese Association for the Study of the Liver.
The GE Portuguese Journal of Gastroenterology publishes original manuscripts on on Gastroenterology, Digestive Endoscopy, Hepatology and related matters. Review articles, clinical cases, images, letters to the editor and other articles are also published and included in the structure of the journal (such as recommendations, articles on gastroenterology clinical practice and notifications of meetings of scientific societies). Articles must be written in English.

A 38-year-old man with a 20-year history of Crohn's disease presented with weight loss, abdominal distention and vomiting. He had been medicated from diagnosis with 5-aminosalicylic acid and later with azathioprine, which he intentionally stopped 2 years later. His last colonoscopy, dating 5 years before, revealed severe ulceration in the ascending and sigmoid colon. On physical examination the patient was severely emaciated. His abdomen was distended, non-tender, and showed markedly reduced bowel sounds (Fig. 1). His vital signs were normal. Laboratory tests showed mild anemia (12.7g/dL) and C-reactive protein (22mg/L), with normal serum electrolytes. Upright abdominal X-ray showed severely distended bowel loops (Fig. 2), later confirmed by abdominal computed tomography. These findings raised our suspicion for the presence of megacolon. As the patient did not presence signs of systemic toxicity we adopted a conservative approach with intravenous steroids, antibiotics, fluid support, daily abdominal X-ray and evaluation by a dedicated surgeon. On the third day of admission, a colonoscopy was performed showing an ulcerated stricture in the terminal ileum that did not allow passage of the endoscope (Fig. 3). The colon showed no signs of active inflammation. Unexpectedly, MRI-enterography showed severe distention (up to 8cm) of a wide segment of the small bowel proximal to a long stricture. The large bowel appeared not to be significantly distended (Fig. 4). The anatomopathologic examination of the small bowel biopsies showed severe transmural inflammation and architectural distortion compatible with Crohn's Disease. There were also multiple nuclear and cytoplasmic inclusions compatible with cytomegalovirus (CMV) infection. As there was suggestion that the stricture could partially be inflammatory and that the patient might benefit from medical therapy, he was started on ganciclovir and Infliximab. Unfortunately, by the 14th week of therapy there was no significant improvement. Due to progressive weight loss, the patient was scheduled for surgery. Examination of the resection specimen confirmed the long 11cm stricture with severe distention of both the small bowel (11cm) and ascending colon (9.5cm).

Figure 1.

Severely emaciated patient with a distended abdomen.

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Figure 2.

Standing abdominal X-ray showing severe dilatation of bowel loops.

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Figure 3.

Colonoscopy showing stenosis and ulceration of the small bowel.

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Figure 4.

MRI-enterography showing contrast enhancement of the last ileal loop (left, arrow) and severe distention of a wide segment of the small bowel (right).

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Crohn's disease is a chronic progressive inflammatory disease. Over time, up to 25% of patients will develop stricturing disease anywhere in the bowel.1,2 While some strictures might temporarily benefit from medical treatment, most will ultimately require surgery.2,3 This case highlights an uncommon but severe complication of Crohn's disease. Due to the rarity and outstanding radiologic findings, the clinical picture was confused with a megacolon, a severe and potential fatal complication, more commonly seen in patients with severe ulcerative colitis.

The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).